You’ve definitely heard of Minoxidil. You’ve probably tried Alpecin or other brands of caffeine shampoo. But have you heard of Nizoral, and in particular its active ingredient, ketoconazole?
We’re about to dive into the very controversial topic of shampoos to stop hair loss.
Please note: We aren’t paid by or affiliated with Nizoral in any way. Any conclusions drawn are done so purely on the weight of scientific evidence available.
What we're going to cover in this article
How may shampoos help to prevent hair loss or even regrow hair?
In Part 1 of our Deep Dive into the causes of hair loss we concluded that DHT was enemy number one for hair and we needed to find ways to either:
a) Reduce DHT production by the body by inhibiting the enzyme 5AR, or
b) Stop DHT from binding to the androgen receptors at the base of our hair follicles
But these are internal approaches to hitting DHT where it hurts. What about topically, is there anything we can do externally in our fight against hair loss? Enter shampoos.
We first need to categorise how a shampoo (well, any topically applied substance, but we will focus on shampoos for the purposes of this article) can function for us. Shampoos can potentially help us in two ways:
1. Cleaning the hair and scalp
– Removing oil and sebum from the scalp
– Cleaning the hairs themselves of oil and dirt
2. Being absorbed by the scalp
– Active ingredients being absorbed into the skin and/or hair follicles
We will return to #1 in a soon coming article as it is an interesting topic of its own. But the remainder of this article will focus on #2.
Both Nizoral (ketoconazole) and Rogaine (minoxidil) both offer topical approaches to combating hair loss but they work in very different ways. Let’s find out more.
What is Ketoconazole (Nizoral)?
Ketoconazole is an anti-fungal medication and the active ingredient in Nizoral shampoo. Nizoral is a shampoo that contains 2% concentration ketoconazole. It is typically used to treat conditions such as seborrheic dermatitis which is caused by Malassezia yeast [1].
Anti-fungals typically work by ‘popping’ fungal cell walls at the microscopic level, causing the cell contents to spill out and hence destroying their functioning, which eventually kills off the wider local yeast infection.
Although ketoconazole applied topically is a relatively harmless over-the-counter product in most countries, it is more controversial when administered orally. The tablet form of this anti-fungal has been linked to potential liver function problems which has lead to both the FDA and the UK government advising against its use.
Does the scientific evidence suggest ketoconazole can stop hair loss or even regrow hair?
The answer seems to be yes. Let’s take a look at the evidence. Given the volume of studies out there, for ease, we decided to present this in a tabular form as shown below.
A green cell means a positive finding for ketoconazole, amber means uncertain findings, and red means a negative finding.
| Year | Main Findings | Link |
|---|---|---|
| 1998 | Study of 39 men found that those washing with 2% ketoconazole 2-4 times per week had a greater number of hairs in growth (manager) phase and thicker hair shafts | Here |
| 1998 | The same team as the study above this time compared ketoconazole to minoxidil. After 6 months, both minoxidil and ketoconazole groups had hair shaft thickness increases of 17%, but the ketoconazole group had an increase in hair density of 18% vs 11% in the minoxidil group | Here |
| 2003 | This study of 150 men found that none of the shampoos tested increased hair density (this includes ketoconazole, but minoxidil was not part of the study), but that hair shedding was the most reduced by ketoconazole (~18%) | Here |
| 2004 | This paper concluded that ketoconazole used in conjunction with finasteride provided a higher level of DHT inhibition than just finasteride use alone | Here |
| 2005 | Study on shaved mice fur showed repeatedly that ketoconazole had a statistically significant stimulatory effect on hair growth | Here |
| 2007 | A small study undertaken with 6 AGA (pattern baldness) patients using only ketoconazole. Of the six, three demonstrated hair regrowth. | Here |
| 2014 | A larger study of 100 patients split into 4 groups as follows. Group 1 received Finasteride alone, Group 2 received Finasteride and minoxidil shampoo, Group 3 received Finasteride and ketoconazole shampoo, and Group 4 received minoxidil alone. The Finasteride and Minoxidil, and Finasteride and ketoconazole groups both showed statistically significant improvement in hair over the other two groups, with Finasteride and Minoxidil being the best combination out of the four. | Here |
The evidence appears to show at worst that ketoconazole is roughly on par with minoxidil, and at best a fantastic tool that offers a new approach to add in our fight against hair loss. This is particularly true given the fact that ketoconazole appears to attempt to bind to our androgen receptors[2], something which minoxidil doesn’t do.
Comparing Ketoconazole vs. Minoxidil
Ketoconazole and minoxidil work in very different ways from one another. Both certainly appear to have their uses, but we see ketoconazole as having one distinct advantage.
Minoxidil is a vasodilator. That means that it increases blood flow to the area in which it is applied. Typically only 1-2% of minoxidil foam is actually absorbed by the skin[3].
It is the metabolite of Minoxidil, minoxidil sulfate, that is the true ‘active’ element that gets to work in supporting our follicles. This metabolite is produced in the presence of the enzyme sulfotransferase which is naturally found in hair follicles but varies by individual and goes some way to explaining why minoxidil is more effective for some people than others.
Minoxidil’s beneficial properties appear to all stem from the fact that it is a potent promoter of blood vessel activity in hair follicles.
In particular, during the anagen (growth) phase of hair follicle life, something known as ‘vascular endothelial growth function’ (VEGF for short) increases significantly with the application of minoxidil[4]. In plain English, this means that the overall health, amount, and functioning of blood vessels is improved by Minoxidil, and the more blood flow, the more oxygen, nutrients, and overall health and strength of the hair follicle itself.
Ketoconazole works differently regarding stopping hair loss and functions in two main ways:
- Fungal infections on the skin are a source of inflammation. Conditions such as seborrheic dermatitis or ringworm, which show themselves as dry flaky red patches of inflamed skin, are caused by Malassezia yeast. Inflammation is an important word when it comes to stopping hair loss and we should do what we can in our power to reduce it.
Although you may be thinking, “But I don’t have a fungal infection”, there are traces of fungus all over our skin, especially in hairier areas of our body such as the scalp which are naturally more oil. As an anti-fungal, ketoconazole eliminates one source of potential inflammation that our hair follicles need to deal with. - Ketoconazole appears to attempt to bind with the hormone receptors (androgen receptors) in our follicles. This is really where ketoconazole shows its real advantage in the battle against hair loss.
As we know, DHT is constantly trying to bind to these receptors. Once bound to them, DHT then sets off a series of actions within the follicles that, on our scalp at least, causes them to start miniaturising and eventually die off.
Ketoconazole ‘battles’ with DHT to bind to those same androgen receptors first, and once bound, it means that less or no DHT can bind to that same site, halting the usual miniaturisation process from starting.
It’s this second point that makes ketoconazole so compelling for us, it works to treat the underlying cause, rather than dealing with the symptom as minoxidil does. By intervening in the process of DHT binding to a follicle’s androgen receptors, it tackles hair loss right at its very root (pun intended).
Suggested usage for hair loss prevention
We would recommend the following based on the methodology used in the studies we analysed:
- Use Nizoral or any other 2% ketoconazole concentration shampoo (as 2% appears more effective than 1% in the fight against hair loss)
- Once in the shower, apply as you normally would any other shampoo but allow it to sit for 3-5 minutes in order for the shampoo to properly soak into and penetrate the scalp (aim for at least 4 minutes)
- Once 3-5 minutes has elapsed, rinse out thoroughly, taking the opportunity to slowly massage the head as you do so
- Apply in this manner no more frequently than every other day, somewhere between every 2-4 days. Anything more doesn’t appear to yield better results
As ever, our advice here is based solely on the scientific evidence assessed. Ketoconazole applied topically appears to be a safe product to use but we would refer you to the disclaimer at the bottom of this page. You should always follow the advice of a healthcare professional and always follow the instructions on the packaging.
Summary
Although an ‘off-label’ use for ketoconazole, the evidence suggests that when applied topically to the scalp, it is effective in the fight against hair loss. This is also true for those taking finasteride (Propecia); ketoconazole can further enhance the inhibition of DHT.
Furthermore, given its price point (currently around £5/$7 for a 60ml/1 month supply), we believe it to be a no brainer to be included as part of your weekly routine.
References Used in this Article
